Complications of intraoperative epidural steroid use in lumbar discectomy: a systematic review and meta-analysis

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>The authors’ aim in this paper was to review the intraoperative use of epidural steroids in lumbar discectomy surgery with a focus on surgical complications.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>A comprehensive literature search was done using PubMed, MEDLINE, and the Cochrane Central Registry of Controlled Trials. Relevant papers were retrieved and analyzed. The authors performed a meta-analysis of all available data. Search terms included epidural, steroids, discectomy, lumbar disc surgery, herniated lumbar disc, methylprednisolone, and perioperative.The primary outcome was surgical complications such as wound infection or need for reoperation. Secondary outcomes were pain and postoperative narcotic usage.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Sixteen trials and 1 retrospective study (a total of 1933 patients) were eligible for inclusion in this study. In all studies, steroids were added epidurally over the nerve root before closure in cases, and control patients underwent discectomy alone. The mean age (42.7 years vs 42.4 years; RR 0.30 [95% CI −0.30 to 0.90], p = 0.32), overall complication rates (2.69% vs 1.18%; RR 1.94 [95% CI 0.72–5.26], p = 0.19), and infectious complication rates (0.94% vs 0.08%; RR 4.58 [95% CI 0.75–27.95], p = 0.10) were similar between the steroid group and control group, respectively.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>There is good evidence that epidural steroids can decrease pain in the short term and decrease the usage of postoperative narcotics after lumbar spinal surgery for degenerative spinal disease. The authors’ results demonstrate a trend toward increased infection with epidural steroid use, but there was not a statistically significant difference. More studies are needed to validate the long-term risk/benefit ratio of epidural steroids in lumbar discectomy.</jats:p></jats:sec>

Efficacy of intraoperative epidural triamcinolone application in lumbar microdiscectomy: a matched-control study

“…With respect to infectious complications, a nonsignificant trend toward more infections in patients receiving ES application was noted (RR 4.58, 95% CI 0.75-27.95, p = 0.10). 2 Our present findings are in line with those of Akinduro et al, 2 as the rates and severity of postoperative complications were similar in both groups (Table 5) despite a nonsignificant trend toward more surgical-site infections in the ES group. There was no higher rate of wound healing problems (minor, not requiring revision surgery; Landriel Ibañez Grade 1) in the ES group (Table 5).…”

“…Steroids are potent suppressors of inflammatory mediators, such as prostaglandins, leukotrienes, bradykinins, and histamines. 2 In line with this pathophysiological concept, ES application has been shown to be associated with reduced pain due to reduction of nerve root edema and inflammation. 22,35 The majority of previous reports were based on retrospective data and compared length of hospitalization, day of first mobilization, and use of mild/ strong pain medication, among other proxies of pain and disability.…”

“…Concerns about the safety of ES application have been raised by authors of smaller series, in particular with respect to deep infections and epidural abscess formation. 2,33 As early as the 1980s, Delaney et al 10 demonstrated in an experimental model that epidural triamcinolone did not result in significant histological changes and that histological findings were in fact comparable to those in controls. A recent systematic literature review analyzing the data of 1933 patients (742 of whom received ES application) revealed similar overall complication rates in patients with and without ES application (risk ratio [RR] 1.94, 95% CI 0.72-5.26, p = 0.19; including infection, arachnoiditis, recurrent LDH, durotomy, and cerebrospinal fluid leak).…”

“…It should be pointed out that the true positive effect of ES application on the clinical outcomes might be underestimated, as the use of postoperative (opioid) analgesics was not standardized and has been reported to be lower in patients who had received ES treatment. 2 On the other hand, ES application was not used in patients with diabetes or in cases where epidural hemorrhage required insertion of a drain, and this could lead to an overestimation of the treatment effect. Only outcomes up to 6 weeks after surgery were considered, which could mask the long-term effects of epidural ES application.…”

Does local lavage influence functional recovery during lumber discectomy of disc herniation?

“…[17–19] However, with this widespread but nonstandardized use of epidural steroids after lumbar discectomy, a better understanding of their associated risks such as a symptomatic CSF leak and the infection, is warranted. [20–21] Local intervertebral irrigation with saline water, which has a better safety, is recommended as the optical alternative for epidural steroid injections. In the present study, VAS scores and ODI decreased significantly in both groups between preoperation and post-operation of different time points.…”